Provider Demographics
NPI:1104101047
Name:PHELPS, AMANDA JO (NP)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:JO
Last Name:PHELPS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3276
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47731-3276
Mailing Address - Country:US
Mailing Address - Phone:812-473-0181
Mailing Address - Fax:
Practice Address - Street 1:220 E VIRGINIA ST
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47711-5530
Practice Address - Country:US
Practice Address - Phone:812-777-0127
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-11
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71003752A363LW0102X, 363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN20104470Medicaid